AFRICAN

stunted economic growth coupled with
competing financial needs against a fixed
budget.
As a signatory to the Abuja Declaration,
Kenya committed itself to allocating
at least 15% of the national budget to
the health sector. 40 However, more than
a decade after signing the declaration,
government funding for health care has
remained consistently below 5%. 41 In
2009–10, the government contributed
30% of the health budget, households
and other private sources contributed
54%, while donors contributed 16%.
However, the total health expenditure
for RH accounted for 14% of total health
spending and 1% of GDP in 2009–10, a
level that has remained unchanged since
2005–2006. 42 Public and private sectors
(including households) were the primary
sources of RH care financing during the
period of analysis with contributions of
40% and 38% respectively. 42 Household
financing of health care is largely through
formal and informal out-of-pocket
payments, which have been linked to poor
uptake of facility services, hence poor
maternal health outcomes. It is against
this backdrop that the Government of
Kenya began implementing the RH
vouchers programme (described in
detail in the next section) in selected
regions of the country. The government
further declared a policy of free maternal
health services (ANC, delivery and PNC
services) in all public health facilities in
2013. 43 Following the policy shift, public
health facilities have reported influxes in
the numbers of maternal delivery. 44
The reproductive health
vouchers programme in
Kenya
Through funding from the German
Development Bank (KfW), an
output-based aid (OBA) RH voucher
programme has been implemented by
the Government of Kenya since 2006.
The OBA concept represents a demandside
approach to financing health care
by subsidizing health-care clients directly
and dispensing money to health facilities
only when services are actually provided.
The programme, described in detail
elsewhere 12,45–47 is implemented in select
sites within three districts (now counties):
(Kisumu, Kitui and Kiambu) and two
urban slums (Viwandani and Korogocho)
in Nairobi since 2006. The programme
was expanded to one additional county
(Kilifi) in 2011. The objective of the
programme is to significantly reduce
maternal and neonatal morbidity and
mortality by increasing the number of
health facility deliveries and improving
access to appropriate RH services
for the poor through incentives for
increased demand and improved service
provision. 8,48,49
Using a non-standard poverty-grading
tool, community-based distributors
appointed by the voucher management
agency screen self-selecting pregnant
women and potential FP clients, who, if
eligible, purchase a safe motherhood or
FP voucher respectively at a minimal fee
or are given for free if living in extreme
poverty. The safe motherhood voucher
costs KSh 200 (US$ 2.50) and covers four
ANC visits, normal or surgical delivery,
pregnancy complications and PNC for
the mother and baby up to six weeks.
The FP voucher costs KSh 100 (US$1.25)
and covers long-term and permanent
methods (contraceptive implants,
intrauterine contraceptive device and
voluntary tubal ligation). A third voucher
for gender-based violence recovery
(GBVR) services is issued for free at
selected health facilities to gender-based
violence (GBV) survivors. The voucher
covers consultation, counselling services,
laboratory examinations and treatment of
conditions arising from GBV.
Beneficiaries present the vouchers for
services at the more than 150 accredited
health (voucher) facilities comprising
public, private for-profit and private notfor-profit.
Following service provision,
facilities submit invoices to the voucher
management agency for payment against
pre-agreed reimbursement rates. The RH
voucher programme has been evaluated
on several facets including its impact on
access to services, 50 impact on quality
of care 51 and the economic costs of
providing the different RH programme
services (unpublished work).
Evaluation of the programme has shown
improved service utilization among the
target population. 49,11,50
Methods
Data
Data for this analysis and paper was
collected during exit interviews with
clients seeking ANC, PNC and FP
services in selected health facilities in
Kenya. The study was conducted between
July and October 2012 as part of a larger
project that evaluated the impact of
reproductive vouchers programmes in
five countries (Kenya, Uganda, United
Republic of Tanzania, Cambodia and
Bangladesh).
A total of 33 health facilities were
randomly sampled from among those
that were accredited to provide services to
voucher beneficiaries. The sampling was
stratified by programme site (Kisumu,
Kitui, Kiambu, Kilifi and Nairobi), facility
level (hospital, health centre/maternity/
nursing home and dispensary/clinic)
and facility type of ownership (public,
private, faith-based and NGO). A further
18 health facilities were sampled from
adjacent non-voucher sites (Makueni,
Nyandarua and Uasin Gishu counties)
for comparison. Health facilities in the
comparison sites were selected on the
basis of how comparable they were to
those sampled from voucher sites in terms
of level and type of ownership. In the
absence of pre-implementation data, the
study authors chose to compare voucher
and non-voucher clients in an effort
to separate the effect of the voucher
programme on stated WTP values.
The study targeted expectant women
making the first (under 24 weeks) and
last (36 weeks or more) ANC visit;
postpartum women seeking PNC services
within 48 hours, two weeks, and four
to six weeks after delivery; and women
seeking FP services. As part of the larger
programme evaluation, the women were
first observed during consultation with
the providers to determine the quality of
care they received. The observations were
conducted by trained nurses who were
deployed outside the study area. Quality
of care assessments were conducted
using a different tool to the one used to
capture stated WTP values. The detailed
methodology and results of the quality of
care assessments are not presented in this
article but covered in detail in a separate
focused paper. 51
ISSUE 20 • SPECIAL ISSUE ON UNIVERSAL HEALTH COVERAGE 45